Friday, June 15, 2012

Healthcare Where Everyone is Above Average

In this essay, above average is bad. Out of range is bad. It is there on black and white, on a piece of paper: you need drugs. And more frequent doctor visits. And frequent diagnostics, mostly involving sucking your blood out, to make sure there are no side effects to the pharmaceuticals and to monitor just exactly where you are in the range.

It is a scam worthy of such greats as Ponzi, Madoff, and Joseph Kennedy. Going to a doctor in the U.S. is like walking into a casino: the odds are against you, the house always wins. When every last penny has been drained from your pocket, they toss you out, to go an earn some more money or to die impoverished in the streets.

Look at the nature of averages. Or more precisely, in this case, what the statistics boys call "median." Half of the population will be above the median, and half below it. The median is defined that way.

Now take some blood tests. Typically blood pressure, triglycerides, glucose, white blood cell count, and a couple of different kinds of cholesterol.

What are the chances, per the statistics boys, that you will have nothing above average, and therefore need no medication (if the average or below is the standard of health)?

Keep in mind this is not about sickness in the ordinary sense of people who feel sick or have obvious symptoms. This is a test that includes healthy people.

Each test is independent, so to get the answer, you just keep multiplying by 1/2. The order does not matter, but let's say it goes like this:

You have a 50% chance of having high blood pressure. 1 times 1/2 is 0.50.

You have a 50% chance of having high triglycerides. 0.50 times 1/2 is 0.25.

You have a 50% chance of having high glucose. 0.25 times 1/2 is 0.125.

In other words, of 1000 people getting this set of tests from a doctor, only 15, maybe 16 will be fully healthy. Everyone else will need some help from the pharmaceutical industry to get "at the lower end of the risk factors."

Just to be sure to pick your pocket, they don't test you against your age class. Most people see a gradual increase in blood pressure as they age. The doctors don't say to you, "for a 60 year-old male, you are below average! See me again in five years." No, you get compared to the healthy 30 year olds. If you are 60 or older, the chances that you have average or better blood pressure are thin. In fact, there may be something wrong with you, like a weak heart.

The human body has been evolving for some 3 billion years. Modern medical science has been around for about a century. Who are you going to trust, Mother Nature or some gal or guy who went to medical school dreaming of making big money?

We don't need everyone to be below average for all health risks. We need to look at what is normal, and only treat conditions that are at least two standard deviations outside of normal. Which means only the roughly 2% of people who get extremely high results, and 2% of people who get extremely low results. May 4% at each end, just to be safe. [This would not apply to actual diseases like diabetes. Everyone with diabetes should get treatment. Almost everyone in the U.S. needs to eat less and exercise more.]

There is likely a good reason that blood pressure increases as we get older. Lowering the blood pressure to a pre-defined standard probably just insures that blood is not getting to where it is needed in our bodies. [This is my hunch, and if someone will grant me a few tens of millions of dollars, I would be happy to hire professionals to test it.] Someday some enterprising scientist will find that "normal" blood pressure causes senior dementia, or some other result worse than the slight increased risk of dying of a heart attack before your kidneys or liver or brain fails.

They never give you unbiased statistics. When have you ever seen a chart of how many people have heart attacks and strokes who don't have high blood pressure? In fact lowering blood pressure, unless you have really, really high blood pressure, is not likely to change your cause of death.

Scientists — real scientists, not the ones funded by industry — will tell you that even when you are trying to do totally honest, accurate science, there is a danger called selection bias. This amounts to rejected data that would prove your bet hypothesis is wrong.

Selection bias can happen even in an academic context. The reason is that certain results, interesting results, are publishable, but the negative results are not. Scientists like to publish. Their careers usually depend on it.
The pharmaceutical companies themselves have found that out when buying potential drugs that academic scientists claimed would be cures. One study by a major pharmaceutical company found that, for almost all of the drug candidates in a batch they bought, they could not replicate the "good" results.

I believe that doctors can help some people some of the time, and in good medical science. But you can't always believe the medical consensus.

Recently a panel of medical experts recommended against a test that has always been supposed to be indicative of prostate cancer, PSA. The knew that PSA results only correlate loosely with prostate cancer. Yet doctors turned high PSA results into a lucrative business of "cures." Looking at a broad range of statistics, the panel found that the negative results from all that expensive "curing," including death during surgery, more than washed away the occasional live saved. Cancer sounds scary, but most prostate cancers evolve slowly. Most men with prostate cancer die of something else, something unrelated. So the panel suggested stopping PSA tests unless there was a good, obvious reason for them. [New Data on Harms of Prostate Cancer Screening, New York Times, May 21, 2012]

Oh, the howls of the financially wounded. The oncologists and urologists, the main beneficiaries of the PSA scam, attacked the panel with vigor. They only care about Science when it is in their financial favor.
The average person is not in a position to argue knowledgeably with their physician about whether they really need a blood pressure or cholesterol pill. Half the American population does not believe in evolution. They don't believe the human body has evolved to optimize its own health and longevity. Sadly, the other half tends to believe in anything presented as science uncritically. In theory they know there is good science and bad science, but in reality they have to rely on their doctors.

We need to rethink medicine from the ground up. We need to ask ourselves how it fits into our other values. Do we let children live in poverty, or underfund our public schools or other important public while paying vast sums for cancer therapies for the over-80 set that, at best, extend miserable lives for a few weeks?
We have evolved a culture that has made us a nation of pill-popping hypochondriacs. Part of this is because costs are masked: for most people, someone else is paying the bill.

I am not against wonder drugs. I am not against necessary surgeries, or preventative medicine that really prevents disease. I want a science-based health system that takes into account economic realities. That is what we need, not what we have.